On Aug. 4, Carlisle Regional Medical Center was still holding patients in its emergency department long after they were classified and billed as inpatients, according to the Pennsylvania Department of Health.

Meanwhile, health insurer Highmark Inc. has expressed concern over the situation and wants information about whether its members received appropriate care.

Inpatients held in the emergency department for extended periods was one of the problems detailed by the Health Department following a June inspection at the South Middleton Twp. hospital.

The hospital had until Aug. 11 to submit a plan of correction. The plan, which must be approved by the Health Department, has yet to be made public.

The Health Department returned to Carlisle Regional on Aug. 4 because of a new complaint related to admitted patients being held in the emergency department, said Christine Cronkright, a Health Department spokeswoman.

Although the problem existed Aug. 4, it has no impact on Carlisle Regional’s effort to bring itself into compliance with state law, and it won’t necessarily impact the state’s stance on the situation, according to Cronkright.

Carlisle Regional officials had no comment on the latest report, which appeared on the Health Department’s website this week.

Most of the problems found during the June investigation centered on not having enough nurses to meet patient-volume demands.

The Health Department detailed high nurse-to-patient ratios and related problems, and said two emergency department deaths might have been related to low staffing.

Carlisle Regional has disputed the contention that the deaths were related to low staffing. However, the hospital said it takes the Health Department’s overall findings seriously and will make changes.

Following the June investigation, the Health Department described many instances in which patients who came to the emergency department were switched to inpatient status, yet remained for long periods in beds in the emergency department.

Once they were classified as inpatients, the change was promptly entered into the computer system, and the patient or their insurer was billed for inpatient care, according to the Health Department.

Patients sometimes remained in a bed in the emergency department for periods ranging from one hour to more than 16 hours, according to the Health Department. The Health Department said it happened more than 200 times between May 22 and June 8.

The situation violates a state law that says the "number of patients admitted to any area of the hospital shall not exceed the number for which the area is designed, equipped, and staffed except in cases of emergency, and then only in accordance with the emergency or disaster plan of the hospital," according to the Health Department.

Government programs such as Medicare and private insurers typically pay more for inpatient care than for standard emergency department care, according to Dr. Carey Vinson, the vice president of quality and medical performance management at Highmark.

However, Vinson said the mere fact that admitted patients might have spent long hours in the emergency department doesn’t cause major concern for Highmark. He said that many hospitals are capable of caring for extremely sick patients in the emergency department. Moreover, circumstances such as full inpatient units sometimes make it necessary.

Still, he said Highmark is concerned about incidents described by the Health Department that raise questions about whether patients held in Carlisle Regional’s emergency department received the level of care they needed.

He wonders, for example, if any of the patients needed intensive care that wasn’t given in an emergency department that the Health Department contends was understaffed.

He said circumstances surrounding the two patients who died are among Highmark’s concerns.

He further said Highmark wants to know if any of its members were among the admitted patients held for long periods in the emergency department, and whether they received the level of care warranted by their condition.

"I think it is an important set of circumstances that should be looked at, because patients can be harmed when these kind of situations occur," Vinson said.

He said Highmark, under its contract with Carlisle Regional, has the right to such information. He also said Highmark has the right to conduct an onsite inspection if it has concerns about care given to its members.

But he said Highmark understands that hospitals often struggle to move patients though the hospital in a highly efficient manner, and Highmark works with hospitals to overcome problems.

Carlisle Regional could eventually be fined by the state.

But the Health Department prefers to work with a hospital to devise and carry out an effective plan of correction, Cronkright said.

She said there is no specific timetable for fixing problems or for when fines kick in. It’s based on factors including the complexity of the problem and the hospital’s history of abiding by regulations, she said.

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